From the Guidelines
For elderly patients with agitation, I strongly recommend starting with non-pharmacological approaches before considering medications, as outlined in the American Psychiatric Association practice guideline 1.
Non-Pharmacological Approaches
When managing agitation in elderly patients, it is crucial to first identify and address potential underlying causes such as pain, infection (especially urinary tract infections), medication side effects, constipation, or unmet needs. Creating a calm environment by reducing noise, maintaining consistent caregivers, and establishing regular routines can also significantly reduce agitation.
Pharmacological Interventions
When medications are necessary, starting with low doses of atypical antipsychotics like quetiapine (12.5-25mg) or risperidone (0.25-0.5mg) at bedtime, titrating slowly while monitoring for side effects, is recommended 1. These medications work by modulating dopamine and serotonin receptors to reduce agitation. It is essential to avoid benzodiazepines when possible as they can worsen confusion and increase fall risk. For patients with dementia-related agitation, considering citalopram (10mg daily) or memantine (5mg daily, titrated up to 10mg twice daily) may be beneficial.
Key Considerations
- Always use the lowest effective dose for the shortest duration necessary.
- Regular reassessment every 1-2 weeks is crucial to evaluate continued need for medication.
- Involve family members in care planning.
- Consider consulting with geriatric psychiatry for complex cases.
- Remember that medication side effects can be more pronounced and dangerous in elderly patients, so close monitoring is essential, as highlighted by the potential risks associated with antipsychotic medications 1.
From the FDA Drug Label
WARNING: INCREASED MORTALITY IN ELDERLY PATIENTS WITH DEMENTIA-RELATED PSYCHOSIS; Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death Quetiapine is not approved for the treatment of patients with dementia-related psychosis
The use of quetiapine in elderly patients with agitation is not recommended due to the increased risk of mortality in elderly patients with dementia-related psychosis. Elderly patients with dementia-related psychosis treated with antipsychotic drugs, including quetiapine, are at an increased risk of death. Therefore, quetiapine should not be used to treat agitation in elderly patients with dementia-related psychosis 2.
From the Research
Causes of Agitation in Elderly Patients
- Agitation in older adults may be due to multiple causes, including primary psychiatric disorders, substance use, hyperactive delirium, and symptoms of dementia 3
- Delirium is an organic mental syndrome defined by a global disturbance in consciousness and cognition, which develops abruptly and often fluctuates over the course of the day 4
- Behavioral changes in older adults can be a manifestation of underlying medical problems, mental health concerns, medication adverse effects, substance abuse, or dementia 5
Management of Agitation in Elderly Patients
- Effective non-pharmacologic modalities are available for the management of mild to moderate agitation and aggression in patients with dementia 3
- Pharmacologic management is indicated for agitation related to a psychiatric condition, severe agitation where a patient is at risk to harm self or others, and to facilitate time-sensitive diagnostic imaging, procedures, and treatment 3
- Emergency physicians have several pharmacologic agents at their disposal, including opioid and non-opioid analgesics, antipsychotics, benzodiazepines, ketamine, and combination agents 3
- A single oral dose of risperidone plus lorazepam was as effective as parenterally administered haloperidol plus lorazepam for the rapid control of agitation and psychosis 6
Assessment and Evaluation of Agitation in Elderly Patients
- Understanding the etiology of agitation in an older adult is critical to proper management 3
- A mental status evaluation is crucial in the diagnosis of delirium 4
- Medical evaluation and stabilization should occur in parallel with the assessment of agitation 4
- The Assess, Diagnose, Evaluate, Prevent, and Treat tool can assist emergency physicians in the care of older adults with agitation or delirium 5